Three-month tolerability of orlistat in adolescents with obesity-related comorbid conditions

Managing obesity in secondary care: a personal practice

Obesity is becoming a common clinical headache for child health professionals, as the increase in professional and media concern has not been matched by effective clinical solutions. Added to this is considerable confusion about both the definitions of obesity and about which groups of children and adolescents actually require treatment. Little guidance exists for paediatricians and other child health specialists on the assessment and management of child and adolescent obesity. Guidelines produced by the American Academy of Pediatrics (AAP) are useful, but require modification for non-American clinical practice. In the UK, the Royal College of Paediatrics and Child Health has recently issued excellent brief guidance on managing obesity in primary care, as has the Scottish Intercollegiate Guidelines Network.

Orlistat: a review of its use in the management of patients with obesity

Orlistat is an inhibitor of gastrointestinal lipases and, therefore, prevents the absorption of dietary fat. This agent reduces weight in obese adults and adolescents with or without comorbidities (including type 2 diabetes mellitus, hypercholesterolaemia, hypertension, metabolic syndrome) who received up to 4 years of therapy in conjunction with a hypocaloric diet. In obese patients, orlistat in combination with a hypocaloric diet improved metabolic risk factors and reduced the risk of developing type 2 diabetes. Furthermore, this agent was cost effective in patients with obesity, particularly those with type 2 diabetes. Orlistat is generally well tolerated, with gastrointestinal adverse events being most commonly reported. Orlistat, in addition to lifestyle and dietary intervention, is thus an attractive option for the treatment of patients with obesity, especially those with associated comorbidities or at risk of developing type 2 diabetes.

Effective oral treatment of unconjugated hyperbilirubinemia in Gunn rats

We sought to develop an oral treatment for unconjugated hyperbilirubinemia. In the Gunn rat model of unconjugated hyperbilirubinemia, dietary supplementation with the lipase inhibitor orlistat (Orl) or with calcium phosphate (CaP) decreases plasma unconjugated bilirubin (UCB) levels. We determined whether Orl, CaP, or their combination is superior to phototherapy, the conventional treatment, and whether the effects of Orl and CaP are influenced by dietary fat content. Gunn rats were treated with Orl (200 mg/kg chow), CaP (20 g/kg chow), Orl + CaP, or continuous phototherapy (19 muW/cm(2)/nm) during a low-fat (LF) diet (13 energy%) or high-fat (HF) diet (35 energy%). Plasma UCB and fecal fat excretion were measured before, during, and/or at the end of treatment. Orl treatment for 2 weeks (HF diet) reduced plasma UCB concentrations similar to phototherapy (-34% and -28%, respectively); the combination of both was more effective than either treatment alone (-48%; P < .001). After 3 weeks of a HF diet, plasma UCB was 46% lower compared with the LF diet (P < .001). Plasma UCB concentrations were negatively correlated with fecal fat excretion (r = -0.96; P < .001). Irrespective of dietary fat content, 3 weeks of combined treatment (Orl + CaP) decreased plasma UCB by approximately 50% (P < .01) and was more effective than phototherapy (P < .05) at the intensity provided. In conclusion, plasma UCB concentrations in Gunn rats are negatively related to fecal fat excretion and dietary fat content. Orlistat is equally effective as phototherapy for the treatment of unconjugated hyperbilirubinemia in Gunn rats, and combined oral treatment with Orl + CaP is more effective than phototherapy. The present results support the feasibility of an efficient oral treatment of unconjugated hyperbilirubinemia.

3. Management and prevention of obesity and its complications in children and adolescents

Obesity in children and adolescents has reached alarming levels--20%-25% of children and adolescents are overweight or obese, and 4.9% of boys and 5.4% of girls are obese. Rates of obesity have increased significantly in Australia from 1985 to 1995, with the prevalence of overweight doubling and obesity trebling. Body mass index (related to reference standards for age and sex) is recommended as a practical measure of overweight and obesity in children, and is used in monitoring individual progress in clinical practice. Obesity in childhood and adolescence may be associated with a range of medical and psychological complications, and can predispose individuals to serious health problems in adult life, including type 2 diabetes, hypertension, dyslipidaemia and non-alcoholic steatohepatitis. Obesity interventions for which there is some evidence include family support, a developmentally appropriate approach, long-term behaviour modification, dietary change, and increased physical activity and decreased sedentary behaviour. Prevention of obesity in children and adolescents requires a range of strategies involving changes in both the microenvironment (eg, housing, neighbourhoods, recreational opportunities) and the macroenvironment (eg, food marketing, transport systems, urban planning).

Addition of orlistat to conventional treatment in adolescents with severe obesity

To investigate the efficacy and tolerability of orlistat in obese adolescents, a prospective, open-label, randomised, controlled pilot trial was performed. A total of 22 adolescents with exogeneous obesity were started on orlistat (120 mg tid) and a daily multivitamin preparation in addition to conventional treatment which included nutritional and lifestyle modification programmes. The control group consisted of 20 obese adolescents who had similar duration of follow-up under conventional treatment alone. Of the 22 patients, 7 dropped out within the 1st month of the trial due to side-effects attributable to orlistat. The remaining 15 patients on orlistat were followed for 5-15 months (average duration of treatment 11.7 +/- 3.7 months). The control group was similar in age, sex, and duration of follow-up (10.2 +/- 3.7 months, range 6-17 months) to the orlistat group. Compared to initial body weight, patients in the orlistat group lost -6.27 +/- 5.4 kg, whereas those in the control group gained 4.16 +/- 6.45 kg (P < 0.001) during the study period. Patients in the orlistat group lost -7.65% +/- 6.5% of their initial body weight, whereas, those of the control group gained 5.7% +/- 8.3% (P < 0.001). The body mass index decreased in the orlistat group by -4.09 +/- 2.9 kg/m2 while it increased by + 0.11 +/- 2.49 kg/m2 in the control group (P < 0.001). Mild gastrointestinal complaints (frequent stools) were experienced by all patients in the orlistat group.

CONCLUSION

Orlistat could be a useful adjunct in the treatment of severe obesity in adolescents; however, gastrointestinal side-effects limit its usefulness in almost one in three adolescents.

New insights into the field of children and adolescents’ obesity: the European perspective

EDITOR'S NOTE

The problem of childhood obesity is accelerating throughout the world. The following is a position paper from The European Childhood Obesity Group (ECOG) that outlines the nature of the problem of childhood obesity along with treatment and prevention methods available today. The paucity of literature on prevention and treatment of obesity in children as documented in this paper points out the need for much additional research on obesity in children.

OBJECTIVES

The awareness of childhood obesity as a major health problem and an uncontrolled worldwide epidemic has to be increased in the society.

DESIGN

In order to improve the quality of the health care and to minimize the cost it is important to investigate and standardize pediatric obesity prevention and treatment and to adapt to social and cultural aspects.

RESULTS

Obesity is the result of excess body fat. The different norms and definitions in Europe and the US is described and clarified. However, the available methods for the direct measurement of body fat are not easily used in daily practice. For this reason, obesity is often assessed by means of indirect estimates of body fat, that is, anthropometrics. There are essentially six relevant levels, which could be involved in prevention of child and adolescent obesity: family (child, parents, siblings, etc), schools, health professionals, government, industry and media. Evidence-based health promotion programs has to be given a high priority. Government should encourage media increase information about healthy nutrition and to avoid the marketing of unhealthy foods including sweet drinks, for example, in TV. Many different approaches of treatments of obesity have been investigated, including diet, exercise, behavioral therapy, surgery, and medication. None have been found to be effective enough as sole tools in children. This has led to focus on multidisciplinary programs especially involving families. Behavioral cognitive therapy is effective in treating childhood obesity as is family therapy. Surgery and drug treatment cannot be recommended without additional research. Clinicians should consider the various factors that can influence body composition.

CONCLUSION

It is important to know and to follow nutritional factors, energy intake and composition of the diet, nutrition and hormonal status, food preferences and behavior, and the influence of non-nutritional factors. We recommend that obesity should be the major priority both in the health care system, on the scientific level and for future political actions.

Comparison of the effect of orlistat vs orlistat plus metformin on weight loss and insulin resistance in obese women

BACKGROUND AND AIM

Orlistat and metformin are the currently used drugs for weight loss. We aimed to compare the effect of orlistat and orlistat plus metformin combination therapy on weight loss and insulin resistance in obese women.

PATIENTS AND METHODS

In all, 57 obese women (body mass index >/=30 kg/m(2) and normal glucose tolerance) were included. All subjects took the same content and caloric diet therapy during the study. After a month of diet period, each individual was randomly assigned to receive 360 mg orlistat per day (group 1; n=30) or 360 mg orlistat plus 1700 mg metformin per day (group 2; n=27) during the next 3 months. Body weight and insulin resistance by the homeostasis model assessment model (HOMA-IR) was measured at baseline, first month and fourth month.

RESULTS

The mean weight loss in groups 1 and 2 was 1.36+/-0.8 kg (1.4+/-0.7%) and 1.11+/-0.7 kg (1.1+/-0.7%) from baseline to first month; 4.8+/-2.9 kg (5.28+/-3.0%) and 5.77+/-2.5 kg (6.17+/-2.9%) from first month to fourth month. Body weight was decreased in groups 1 (P< 0.001) and 2 (P< 0.001), but there was no statistically significant difference between groups. Change of HOMA-IR in groups 1 and 2 was 0.41+/-0.4 (14.9+/-10.1%) and 0.23+/-0.7 (8.16+/-12.3%) from baseline to first month; 0.49+/-0.77 (22.0+/-26%) and 0.95+/-0.88 (34.8+/-29.1%) from first month to fourth month. HOMA-IR value was decreased in groups 1 (P< 0.001) and 2 (P< 0.001) but was not different between groups during the study period.

CONCLUSIONS

Combination of orlistat with metformin did not result in an additional effect on weight loss and insulin resistance when compared to orlistat alone in our study. However, new studies which have more sample sizes and the longer study period are necessary for this purpose.

Efficacy of orlistat as an adjunct to behavioral treatment in overweight African American and Caucasian adolescents with obesity-related co-morbid conditions

This pilot study compared the efficacy of orlistat as an adjunctive treatment for obesity between African American and Caucasian adolescents. Twenty obese adolescents with obesity-related co-morbid conditions underwent measurements of body composition, glucose homeostasis by frequently sampled intravenous glucose tolerance test (FSIGT), and fasting lipids before and after 6 months treatment with orlistat 120 mg tid in conjunction with a comprehensive behavioral program. Weight (p < 0.05), BMI (p < 0.001), total cholesterol (p < 0.001), LDL cholesterol (p < 0.001), fasting insulin (p < 0.02) and fasting glucose (p < 0.003) were lower after treatment. Insulin sensitivity, measured during the FSIGT, improved significantly (p < 0.02), as did fasting indices such as the homeostasis model assessment for insulin resistance (p < 0.01). African American subjects exhibited significantly less improvement in weight (p < 0.05), BMI (p < 0.01), waist circumference (p = 0.03), and insulin sensitivity (p = 0.05). Improvements in cholesterol were not significantly different between African Americans and Caucasians. We conclude that Caucasians lost more weight and had greater improvements in insulin sensitivity than African Americans, but both exhibited improvements in plasma lipids. The true benefit of orlistat treatment over a comprehensive behavioral program remains to be determined in placebo-controlled trials.

Managing overweight in older children and adolescents

Because overweight and obesity are chronic health conditions, long-term management is necessary, with particular attention to comorbidities. Lifestyle modification including changes in diet and activity can be accomplished in the primary care setting. Many overweight and obese children and adolescents can achieve weight loss of 0.5 kg per week even over long periods. For some severely obese children, pharmacotherapy or surgery may be necessary.

Sequence variants of the POMC gene and their associations with body composition in children

We investigated POMC sequence variants in 242 overweight and nonoverweight African-American and white children and examined the associations between body composition and POMC polymorphisms. Three novel polymorphisms and two previously identified sequence variants were found: A7301G, A7429G, and C8246T were all in untranslated regions. A 9-bp (AGC AGC GGC) duplication/insertion was found between positions 7677 and 7678, and one normal-weight African-American girl had a 45-bp triple duplication/insertion at this location. Compared with whites, African-American children were significantly more likely to have polymorphisms A7301G, A7429G, and the 9-bp insertion. However, there were no significant associations between any of the polymorphisms and body composition. Five African-American subjects who were homozygous for A7429G had a trend (p = 0.08) for a greater BMI-SD score (5.3 +/- 5.3 kg/m(2)) compared with wild-type children (BMI-SD score, 2.4 +/- 3.2 kg/m(2)) or heterozygotes (BMI-SD score, 2.7 +/- 3.7 kg/m(2)). However, there were no differences in BMI-SD score for A7429G when African American subjects were studied separately and both gender and height were taken into account. The contribution of the POMC gene variants we studied to pediatric-onset obesity seems to be limited.